CASE REPORT Open Access

First COVID-19 infections in the Philippines:a case reportEdna M. Edrada1, Edmundo B. Lopez1, Jose Benito Villarama1, Eumelia P. Salva Villarama1, Bren F. Dagoc1,Chris Smith2,3*, Ana Ria Sayo1, Jeffrey A. Verona1, Jamie Trifalgar-Arches1, Jezreel Lazaro1, Ellen Grace M. Balinas1,Elizabeth Freda O. Telan1, Lynsil Roy1, Myvie Galon1, Carl Hill N. Florida1, Tatsuya Ukawa2,Annavi Marie G. Villanueva2, Nobuo Saito4, Jean Raphael Nepomuceno2, Koya Ariyoshi5, Celia Carlos6,Amalea Dulcene Nicolasora6 and Rontgene M. Solante1

Abstract

Background: The novel coronavirus (COVID-19) is responsible for more fatalities than the SARS coronavirus, despitebeing in the initial stage of a global pandemic. The first suspected case in the Philippines was investigated onJanuary 22, 2020, and 633 suspected cases were reported as of March 1. We describe the clinical andepidemiological aspects of the first two confirmed COVID-19 cases in the Philippines, both admitted to the nationalinfectious disease referral hospital in Manila.

Case presentation: Both patients were previously healthy Chinese nationals on vacation in the Philippinestravelling as a couple during January 2020. Patient 1, a 39-year-old female, had symptoms of cough and sore throatand was admitted to San Lazaro Hospital in Manila on January 25. Physical examination was unremarkable. InfluenzaB, human coronavirus 229E, Staphylococcus aureus and Klebsiella pneumoniae were detected by PCR on initialnasopharyngeal/oropharyngeal (NPS/OPS) swabs. On January 30, SARS-CoV-2 viral RNA was reported to be detectedby PCR on the initial swabs and she was identified as the first confirmed COVID-19 case in the Philippines. Hersymptoms resolved, and she was discharged. Patient 2, a 44-year-old male, had symptoms of fever, cough, andchills. Influenza B and Streptococcus pneumoniae were detected by PCR on initial NPS/OPS swabs. He was treated forcommunity-acquired pneumonia with intravenous antibiotics, but his condition deteriorated and he requiredintubation. On January 31, SARS-CoV-2 viral RNA was reported to be detected by PCR on the initial swabs, and hewas identified as the 2nd confirmed COVID-19 infection in the Philippines. On February 1, the patient’s conditiondeteriorated, and following a cardiac arrest, it was not possible to revive him. He was thus confirmed as the firstCOVID-19 death outside of China.

Conclusions: This case report highlights several important clinical and public health issues. Despite both patientsbeing young adults with no significant past medical history, they had very different clinical courses, illustrating howCOVID-19 can present with a wide spectrum of disease. As of March 1, there have been three confirmed COVID-19cases in the Philippines. Continued vigilance is required to identify new cases.

Keywords: Case report, COVID-19, SARS-CoV-2, Coronavirus, Philippines, Manila

© The Author(s). 2020, corrected publication [2020]. Open Access This article is licensed under a Creative CommonsAttribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium orformat, as long as you give appropriate credit to the original author(s) and the source, provide a link to the CreativeCommons licence, and indicate if changes were made. The images or other third party material in this article are included inthe article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included inthe article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds thepermitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visithttp://creativecommons.org/licenses/by/4.0/.

* Correspondence: christopher.smith@lshtm.ac.uk2School of Tropical Medicine and Global Health, Nagasaki University,Nagasaki, Japan3Faculty of Infectious and Tropical Diseases, London School of Hygiene andTropical Medicine, London, UKFull list of author information is available at the end of the article

Tropical Medicineand Health

Edrada et al. Tropical Medicine and Health (2020) 48:21 https://doi.org/10.1186/s41182-020-00203-0

http://crossmark.crossref.org/dialog/?doi=10.1186/s41182-020-00203-0&domain=pdfhttp://creativecommons.org/licenses/by/4.0/mailto:christopher.smith@lshtm.ac.uk

BackgroundThe novel coronavirus 2019 (COVID-19) is responsiblefor more fatalities than the severe acute respiratory syn-drome (SARS) coronavirus, despite being in the initialstage of a global pandemic. It is thought that the indexcase occurred on December 8, 2019, in Wuhan, China[1]. Since then, cases have been exported to other Chin-ese cities, as well as internationally, highlighting concernof a global outbreak [2]. The first suspected case in thePhilippines was investigated on January 22, 2020, and633 suspected cases have been reported as of March 1.Of them, 183 were in the National Capital Region ofManila, of whom many were admitted to San LazaroHospital (SLH) in Manila, the national infectious diseasereferral hospital [3, 4]. We describe the epidemiologicand clinical characteristics of the first two confirmedCOVID-19 cases in the Philippines, including the firstdeath outside China.

Case presentationIn this case report, we describe two cases: patient 1, thefirst confirmed COVID-19 case, and patient 2, the

second confirmed case, even though the symptoms ofpatient 2 started first. The cases are presented based onreports from the clinicians involved in patient care andresults of investigations available to them at the time.Figure 1 shows a timeline of symptoms for both patientsaccording to the day of illness and day of hospitalisation.

History prior to hospitalisationBoth patients were Chinese nationals on vacation in thePhilippines travelling as a couple. They had no knowncomorbidities and reported no history of smoking. Pa-tient 2, a 44-year-old male, reported fever on January 18,2020, whilst the couple were residing in Wuhan, China.It was reported that he was in contact with someonethat was unwell in Wuhan, but not that he had visitedthe seafood market. During January 20 to 25, they trav-elled from Wuhan via Hong Kong to several locations inthe Philippines (Fig. 2). Patient 1, a 39-year-old female,developed cough and sore throat on January 21. Due topersistence of symptoms of patient 2, they travelled toManila on January 25. In Manila, patient 2 was deniedentry to a hotel because he was febrile and both patients

Fig. 1 Timeline of symptoms according to day of illness and day of hospitalisation

Edrada et al. Tropical Medicine and Health (2020) 48:21 Page 2 of 7

were transferred to San Lazaro Hospital (SLH), the na-tional referral hospital for infectious diseases [4]. On ad-mission, patient 2 was classified as a COVID-19 personunder investigation (PUI) based on his travel history andfever [2] and was transferred to a designated isolationarea with negative pressure rooms. Patient 1 did not fitthe PUI criteria due to absence of fever, but was also iso-lated because of possible exposure.

Clinical course of patient 1On admission to the ward on January 25 (illness day 5),patient 1 complained of a dry cough, but the sore throathad improved. She was awake and conversant with ablood pressure of 110/80, HR 84, RR 18 and temperature36.8 °C. Her chest was clear. The remainder of the phys-ical examination was unremarkable. Nasopharyngeal and

oropharyngeal swab (NPS/ORS) specimens were collectedand sent to the Research Institute for Tropical Medicine(RITM) in Muntinlupa City [5]. A chest radiograph wasreported as unremarkable (Fig. 3).On January 27, the results were released of a commercially

available respiratory pathogen multiplex real-time PCR fordetection of pathogen genes on the NPS/OPS samples (FTDRespiratory pathogens 33, Fast Track Diagnostics) at theRITM Molecular Biology Laboratory. These assays reporteddetection of Influenza B viral RNA, human coronavirus 229Eviral RNA, Staphylococcus aureus DNA and Klebsiella pneu-moniae DNA. A 10-day course of oseltamivir 75 mg BIDwas given on the basis of the influenza result. The NPS/OPSspecimen was then sent by RITM to the Victorian InfectiousDisease Reference Laboratory (VIDRL) in Melbourne,Australia, for COVID-19 testing [6].

Fig. 2 Travels of patient 1 and 2

Edrada et al. Tropical Medicine and Health (2020) 48:21 Page 3 of 7

On January 29, further NPS/ORS specimens were col-lected and sent to the RITM. On January 30, the resultof the initial NPS/OPS sent to VIDRL reported detectionof 2019-nCoV (subsequently termed SARS-CoV-2) viralRNA by real-time PCR. The patient was thus identifiedby the Department of Health as the first confirmedCOVID-19 case in the Philippines [6].On illness days 6 to 10, she remained afebrile with

minimal cough and clear breath sounds. During thistime, real-time PCR for detecting SARS-CoV-2 wasestablished at the RITM using the Corman et al. proto-col [7]. Further NPS/OPS specimens collected on Janu-ary 29 (reported on January 31) and January 31(reported on February 2) also reported detection ofSARS-CoV-2 viral RNA. On illness day 11, the patientreported resolution of symptoms. She remained afebrileand clinically stable apart from two episodes of loosewatery stool on illness day 12. Further samples were col-lected on February 2 and 4. On February 8 (illness day19), she was discharged when SARS-CoV-2 was no lon-ger detected on an NPS/OPS sample.

Clinical course of patient 2In contrast, patient 2 experienced a more severe clinicalcourse. On admission (illness day 8), he reported fever,cough and chills. On examination, he was awake andconversant with a temperature of 38.3 °C, blood pressureof 110/80, HR 84, RR 18, and SpO2 of 96% on room air.His chest was clear. The remainder of the physicalexamination was unremarkable.

A working diagnosis of community-acquired pneumo-nia and COVID-19 suspect was made. He was started onceftriaxone 2 g intravenously (IV) once daily (OD) andazithromycin 500 mg OD. NPS/ORS specimens werecollected and sent to the RITM. On January 27, the re-sults of a respiratory pathogen real-time PCR detectionpanel performed at RITM on the NPS/OPS sampleswere released, reporting detection of Influenza B viralRNA and Streptococcus pneumoniae DNA. The NPS/OPS samples were sent to the VIDRL for additional test-ing. Oseltamivir 75 mg BID was commenced on thebasis of the influenza result.During illness days 9 and 10, his fever continued with oc-

casional non-productive cough. He remained clinicallystable apart from intermittent SpO2 desaturations of 93–97% on 2–3 L/min of oxygen. On illness day 11, he devel-oped increasing dyspnoea with reduced SpO2 at 88%despite 8 L/min of oxygen via a face mask and haemoptysisand was noted to have bilateral chest crepitations. A chestradiograph was reported as showing hazy infiltrates in bothlung fields consistent with pneumonia (Fig. 4). Meropenem2 g IV three times a day (TDS) was commenced.On illness day 12, he became increasingly dyspnoeic,

hypoxic and agitated and was intubated and sedatedwith a midazolam drip. An endotracheal aspirate (ETA)and a further NPS/OPS were collected and sent to theRITM. Vancomycin, 30 mg/kg loading dose followed by

Fig. 3 Posteroanterior chest radiograph of patient 1, 27 January2020 (illness day 7). Unremarkable

Fig. 4 Posteroanterior chest radiograph of patient 2, 27 January2020 (illness day 10). Hazy infiltrates in both lung fields consistentwith pneumonia

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25 mg/kg BD, was commenced with a working diagnosisof severe community-acquired pneumonia due toStreptococcus pneumoniae secondary to Influenza B in-fection, plus consideration of COVID-19 pending the

ETA result. A complete blood count showed valueswithin the normal range (Table 1). On illness day 13, hecontinued to be febrile (38.5–40.0 °C) with bibasalcrackles. Vital signs were stable with adequate urine

Table 1 Clinical laboratory results and vital signsHospital day 1 2 3 4 5 6 7 8

Illness day 5 6 7 8 9 10 11 12

Patient 1 Refvalues

Temp (°C) 36.8

BP (mmHg) 110/80

Pulse (/min) 84

Resp (/min) 18

O2 sat (%)

NPS/OPS PCR collected Influ. B(+)Kl. pneumo (+)S. aureus (+)CoV 229E (+)

SARS-CoV-2 (+)

NPS/OPS PCR collected SARS-CoV-2 (+)

NPS/OPS PCR* collected

Illness day 8 9 10 11 12 13 14 15

Patient 2 Refvalues

Temp (°C) 38.3 38.8 37.9 38.8 38.1 40 40 40

BP (mmHg) 110/80

110/70 120/80 120/80 130/80 110/70 110/70 110/70

Pulse (/min) 84 86 98 85 94 95 95 95

Resp (/min) 18 22 22 23 38 30 30 30

O2 sat (%) 96%RA

93% 3L O2 NP 88% 6L O2FM

91% at 15L O2FM➔>90% @ 100% Fi02MV

99% @100% FiO2MV

98% @ 800% FiO2MV

99%@ 80% FiO2MV

WBC (109/l) 4.0 – 10.0 5.06 9.45

Neutro (%) 55 -65 89.9 85.6

Lymph (%) 25 – 35 7.7 12.2

Mono (%) 3.0 – 8.0 2.4 1.6

Eosino (%) 2.0 – 4.0 0.5

Baso (%) 0 – 1.0 1.6

Hgb (g/l) 120 –160

143 142

Hct 0.37 –0.43

0.41 0.41

Plat (x109/l) 150 –400

188

NPS/OPSPCR**

collected Influ. B (+)S. pneumo (+)

NPS/OPS PCR collected SARS-CoV-2 (+)

ET aspirate PCR collected

Blood culture collected (-) growth

HIV screen non-reactive

Date Jan 25 Jan 26 Jan 27 Jan 28 Jan 29 Jan 30 Jan 31 Feb 1

NPS/OPS nasopharyngeal/ oropharyngeal swab, ETA endotracheal aspirate*NPS/OPS—result from RITM was received on February 2 and reported detection of SARS-CoV-2 viral RNA**NPS/OPS—result from VIDRL was received on February 4 and reported detection of SARS-CoV-2 viral RNA

Edrada et al. Tropical Medicine and Health (2020) 48:21 Page 5 of 7

output. A chest radiograph was reported as showingworsening of pneumonia (Fig. 5).On illness day 14, increased crepitations in both lung

fields were noted. Blood cultures showed no growthafter 24 h of incubation. An HIV test was non-reactive.On this day, the RITM reported detection of SARS-CoV-2 viral RNA by real-time PCR from the NPS/OPStaken on illness day 12 and hence the 2nd confirmedCOVID-19 infection in the Philippines. This result waslater confirmed on February 4 on the initial admissionsample sent to VIDRL.On the morning of illness day 15, the patient remained

febrile at 40 °C, with BP 110/70, HR 95, RR 30, SpO2 99%with 80% FiO2, and adequate urine output. However, thepatient’s condition deteriorated with the formation ofthick sputum and blood clots in the ET tube. Despite fre-quent suctioning, the patient’s condition deteriorated. Hewas noted to have laboured breathing followed by a car-diac arrest. Despite several rounds of cardiopulmonary re-suscitation, it was not possible to revive the patient. Hewas thus confirmed as the first COVID-19 death outsideof China.

Discussion and conclusionThis case report describes the first two confirmed casesof COVID-10 in the Philippines and highlights severalimportant clinical and public health issues. Despite bothpatients being young adults with no significant past

medical history, they had very different clinical courses,illustrating how COVID-19 can present with a widespectrum of disease [8]. Whilst patient 1 had a mild un-complicated illness consistent with an upper respiratorytract infection and recovery, patient 2 developed a severepneumonia and died.One possible explanation for the differing clinical

courses is the presence of co-infection. In both patients,the real-time PCR detection panel was reported to bepositive for multiple pathogens. The Staphylococcus aur-eus and Klebsiella pneumoniae detected in patient 1most likely represent bacterial colonisation, and it is un-clear to what extent her presentation was due to influ-enza or COVID-19 or both. Patient 2 tested positive forCOVID-19, Influenza B, and Streptococcus pneumoniae,all of which can cause respiratory infection and severepneumonia. Unfortunately, sputum culture was not pos-sible due to biosafety concerns. It is unclear whichpathogen was the leading cause of death, but previousresearch has shown that outcomes of acute viral respira-tory infection are worse if multiple pathogens arepresent [9]. This highlights the importance of testing forother respiratory pathogens in addition to COVID-19 inorder to optimise antimicrobial therapy.Patient 2 developed increasing dyspnoea on day 11 of

illness, similar to the first COVID-19 case in the USA,where mild symptoms were initially reported with pro-gression to pneumonia on day 9 of illness [10]. The me-dian time from illness onset to dyspnoea in a case series inWuhan was 8 days (range 5–13) [11]. The explanation forpatient 2’s worsening condition and development ofhaemoptysis was progression of pneumonia rather thanacute respiratory distress syndrome or pulmonary embol-ism, but it was not possible to perform a CT scan, add-itional laboratory tests or an autopsy to further assess this.Although he was treated with broad-spectrum antimicro-bials, it is not clear if the outcome would have been betterin a high-resource setting. Both patients were treated withoseltamivir in view of positive results for Influenza B. Fur-ther studies are required to establish the optimal treat-ment and role of antiviral medication for patients withsuspected or confirmed COVID-19 infection.Our cases contrast with the US case in terms of the

relative paucity of lab data and time to receive results.Limited in-house testing was undertaken due to bio-safety concerns. In the case of patient 2, the diagnosis ofCOVID-19 was not made until a day before the patientdied. This was because SARS-2-CoV testing was beingestablished in the Philippines at the time that the pa-tients were admitted, and initial samples had to be sentto Australia. Although the delay of diagnosis is unlikelyto have altered management, expansion of COVID-19diagnostics including multiplex panels for other respira-tory pathogens is urgently needed for prompt diagnosis

Fig. 5 Posteroanterior chest radiograph of patient 2, 30 January2020 (illness day 13). Endotracheal tube in situ approximately 2 cmabove the carina. There is worsening of the previouslynoted pneumonia

Edrada et al. Tropical Medicine and Health (2020) 48:21 Page 6 of 7

of patients for screening of hospital personnel or othercontacts.Three SLH hospital staff who were caring for the pa-

tients developed symptoms and themselves becamePUIs, but were later discharged following negativeSARS-CoV-2 testing and symptom resolution. This high-lights the risk of an outbreak in the hospital, or a ‘super-spreader’ scenario, as was observed in other settingsduring the early stages of the SARS coronavirus infec-tions in 2003 [12]. In the case of SARS, as with COVID-19, SLH managed two cases and was able to contain theinfection without further spread [13].The third confirmed COVID-19 case was announced

on February 3 from a sample taken on January 23, also aChinese national who had travelled from Wuhan. Sherecovered and returned to China on January 31. Contacttracing has been undertaken of all three patients [14].Despite travel to several locations in the Philippineswhilst experiencing symptoms, as of March 1, there hasnot been any confirmed local transmission arising fromthese cases and the number of PUIs has decreased [3].However, as infection can be mild or subclinical, localtransmission cannot be excluded. Increasing the numberof laboratories able to perform SARS-CoV-2 testingwould allow better surveillance and improve detection ofCOVID-19 cases.In conclusion, as of March 1, there have been three

confirmed COVID-19 cases in the Philippines includingthe first death outside of China. No local transmissionhas been confirmed. Continued vigilance is required toidentify new cases.

AbbreviationsCOVID-19: Coronavirus disease 2019; nCoV: Novel coronavirus; NPS/OPS: Nasopharyngeal swab/oropharyngeal swab; PCR: Polymerase chainreaction; PUI: Person under observation; RITM: Research Institute for TropicalMedicine; SARS: Severe acute respiratory syndrome; SLH: San Lazaro Hospital

AcknowledgementsWe are very grateful to the patients for allowing us to prepare and publishthis case report.

Authors’ contributionsAll of the authors contributed to the writing of this case report. The authorsread and approved the final manuscript.

FundingNot applicable

Availability of data and materialsN/A

Ethics approval and consent to participateThis case report was not part of a research study, and hence, ethicalapproval was not sought. Written consent was obtained from patient 1 andon behalf of patient 2.

Consent for publicationWritten consent for the preparation and publication of a case report wasprovided by patient 1 and on behalf of patient 2, following discussion withhis brother.

Competing interestsThe authors declare that they have no competing interests.

Author details1San Lazaro Hospital, Manila, Philippines. 2School of Tropical Medicine andGlobal Health, Nagasaki University, Nagasaki, Japan. 3Faculty of Infectious andTropical Diseases, London School of Hygiene and Tropical Medicine, London,UK. 4Department of Microbiology, Faculty of Medicine, Oita University, Oita,Japan. 5Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan.6Research Institute for Tropical Medicine, Alabang, Philippines.

Received: 2 March 2020 Accepted: 22 March 2020

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http://www.nejm.org/doi/10.1056/NEJMoa2001017http://www.nejm.org/doi/10.1056/NEJMoa2001017https://www.doh.gov.ph/node/19197https://www.doh.gov.ph/node/19197http://slh.doh.gov.ph/http://ritm.gov.ph/https://www.vidrl.org.au/https://doi.org/10.1016/S0140-6736(20)30183-5https://doi.org/10.1016/S0140-6736(20)30183-5http://www.ncbi.nlm.nih.gov/pubmed/32007143https://www.doh.gov.ph/doh-press-release/doh-confirms-3rd-2019-nCoV-ARD-case-in-PHhttps://www.doh.gov.ph/doh-press-release/doh-confirms-3rd-2019-nCoV-ARD-case-in-PH

AbstractBackgroundCase presentationConclusions

BackgroundCase presentationHistory prior to hospitalisationClinical course of patient 1Clinical course of patient 2Discussion and conclusionAbbreviationsAcknowledgementsAuthors’ contributionsFundingAvailability of data and materialsEthics approval and consent to participateConsent for publicationCompeting interestsAuthor detailsReferencesPublisher’s Note